Anke Steins

Microcirculatory Dysfunction in Chronic Venous Insufficiency (CVI)

The elevated ambulatory pressure in the peripheral venous system of chronic venous insufficiency (CVI) patients manifests itself not only in the form of disturbed macrocirculation but also and particularly in microangiopathic changes. For this reason, it is closely correlated with trophic disorders of the skin and can ultimately lead to ulceration. Using microcirculation research techniques, we are able to provide clear evidence of a typical microangiopathy in chronic venous insufficiency. Fifty CVI patients in Widmer stages I, II, and III were examined with fluorescence video microscopy, intravital video capillaroscopy, transcutaneous oxygen partial pressure measurement, TcpO2 and laser Doppler flowmetry. The effects of compression therapy with individually fitted compression stockings on capillary morphology were studied over a period of 4 weeks in 20 CVI patients in Widmer stages I and II. The capillary pressure was measured during simulated muscle contraction using a servo‐null micropressure system. We periodically drew blood from the dorsalis pedis vein and a brachial vein of 11 healthy test persons and 8 patients with stage III CVI during experimental venous hypertension in order to evaluate the expression pattern of leukocyte adhesion molecules involved in inflammation: LFA‐1 (CD11a), Mac‐1 (CD11b), p150,95 (CD11c), CD18, VLA‐4 (CD49d), and L‐selectin (CD62L). In the same patients, we used immunohistochemical methods to examine clinically unaffected skin and the skin near an ulcer, focusing on the adhesion molecules ICAM‐1, VCAM‐1, and E‐selectin. The microangiopathic changes observed with worsening clinical symptoms include a decrease in the number of capillaries, glomerulus‐like changes in capillary morphology, a drop in the oxygen content (tcpO2) of the skin, increased permeability of the capillaries to low‐molecular‐weight substances, increased laser Doppler flux reflecting elevated subcutaneous flow, and diminished vascular reserve. These microangiopathic changes worsen in linear proportion to the clinical severity of chronic venous insufficiency. In patients with venous ulcerations, the baseline expression of LFA‐1 and VLA‐4 on lymphocytes, Mac‐1 expression on the myeloid cell line, and L‐selectin expression on all three cell lines was not significantly different from that in healthy controls. During orthostatic stress, there was a significant reduction in the expression of L‐selectin in blood cells collected at foot level in the controls (p = 0.002), but not in the patients. Clinical improvement by compression therapy was accompanied by an increase in the number of nutritive capillaries, while the diameter of the capillaries and the dermal papillae was reduced. When ulcers healed in a short period (<6 weeks), we observed a concomitant increase in the number of capillaries (p < 0.05). Microangiopathy appears before trophic disorders of the skin develop. Even trophically normal skin areas may have dilated nutritive capillaries, an early sign of disturbed skin perfusion. These changes represent a plausible explanation for the development and to recurrency tendency of venous ulcers. The reduced expression of lymphocytic L‐selectin in healthy controls during the orthostatic stress test may be an indication that the cells are activated by venous stasis. Clinically effective therapeutic measures improve the impaired microcirculation of the skin in the ankle area.

Behandlung von venösen Ulzera mit niederfrequentem gepulstem Strom (Dermapulse) : Effekte auf die kutane Mikrozirkulation

ZusammenfassungDie chronische Veneninsuffizienz (CVI) ist gekennzeichnet durch eine stadienabhängige Mikroangiographie. Mit zunehmendem Schweregrad verringern sich die Anzahl der Hautkapillaren, der Sauerstoffpartialdruck und die kutane vaskuläre Reserve, die durch den Laser-Doppler-Flux gemessen wird, nehmen ab. Diese kutane Mikroangiographie gehört zu den Hauptursachen für die bei der CVI auftretenden trophischen Störungen. Die Therapie mit niederfrequentem gepulstem Strom verbessert die kutane Mikrozirkulation bzw. Nutrition und beschleunigt die Ausbildung von Granulationsgewebe. Die klinische Wertigkeit dieses Therapieprinzipes zur Behandlung chronisch venöser Beinulzera wurde in einer offenen prospektiven Pilotstudie evaluiert. Es wurden 15 Patienten mit niederfrequentem gepulstem Strom (Dermapulse) behandelt. Das mittlere Alter betrug 70,3 Jahre. Bei einer durchschnittlichen Ulkusdauer von 79,1 Monaten wurden die Patienten über eine Zeitdauer von 38 Tagen im Rahmen einer Anwendungsstudie behandelt. Unter dieser Behandlung zeigte sich bei 2 Patienten eine Ulkusabheilung, bei 13 Patienten eine Ulkusverkleinerung um 63%. Die Kapillardichte nahm um 43,5% zu, der transkutane Sauerstoffpartialdruck stieg um 82,4%. Die Elektrostimulationsbehandlung erwies sich dabei als nebenwirkungsarme Behandlungsmethode.SummaryChronic venous insufficiency (CVI) is characterised by stage-dependent microangiopathy. With increasing severity there is a decrease in the number of skin capillaries and the oxygen partial pressure. The cutaneous vascular reserve, which is measured by laser-doppler fluxmetry, is reduced. Cutaneous microangiopathy is one of the main causes of the trophic disturbances associated with CVI. Low frequency pulsed current improves cutaneous microcirculation and thus nutrition as well as accelerating the formation of granulation tissue. In a open prospective pilot study, 15 patients suffering from CVI with persistent leg ulcers were treated with low frequency pulsed current (Dermapulse), which is thought to improve particularly the tissue microcirculation. The average age of the patients was 70.3 years and the average duration of ulceration was 79.1 months. The patients were treated over a period of 38 days. With this treatmen, 2 ulcers healed completely and 13 showed a reduction of size of on average 63%. Capillary density increased by 43.5%, while transcutaneous oxygen partial pressure increased by 82.4%. Electrostimulation is a treatment with few or no side effects.

Einfluß einer Kompressionstherapie auf die Mikro- zirkulation der Haut bei Patienten mit chronischer Veneninsuffizienz (CVI)

ZusammenfassungBei 20 Patienten mit chronischer Veneninsuffizienz in den Stadien CVI I und CVI II (in der Klassifikation nach Widmer) wurde eine 4wöchige Kompressionstherapie durchgeführt. Einer zunächst 2wöchigen Behandlung mit Kurzzugkompressionsbinden folgte eine gleich lange Therapiephase mit maßgefertigten Kompressionsstrümpfen der Klasse 2. Vergleichende Untersuchungen wurden vor Therapiebeginn, nach Ende der ersten Therapiephase sowie bei Abschluß der vierwöchigen Kompressionstherapie durchgeführt. Unter der 4wöchigen Therapie kam es zu einer deutlichen Abnahme subjektiver Beschwerden, wie Schmerzen und Juckreiz am Bein, zu einer signifikanten Verminderung des Unterschenkelvolumens sowie einer Zunahme der Kapillardichte im Stauungsareal bei gleichzeitiger Verkleinerung der initial vergrößerten Kapillardurchmesser und perikapillären Halos. Die klinische Bedeutung und Wirksamkeit der Kompressionstherapie als Basistherapie bei der chronischen Veneninsuffizienz erklärt sich damit auch durch die nachweisbare Verbesserung der kutanen Mikrozirkulation. Der Vergleich zur Effektivität von Kompressionsbinden bzw. Kompressionsstrümpfen erbrachte nur geringgradige Unterschiede zwischen den beiden Therapievarianten.SummaryCompression therapy was employed for 4 weeks 20 patients with chronic venous insufficiency stage CVI I and CVI II according to Widmer’s classification. Compression bandaging for 2 weeks was followed by compression stockings for 2 more weeks. The cutaneous microcirculation was evaluated before therapy, after 2 weeks and after finishing compression therapy after 4 weeks. Marked improvement in symptoms such as pain and itching was observed after 4 weeks, along with a significant reduction in lower limb volume. Video capillary microscopy revealed an increase in capillary density associated with a decrease in capillary diameter and pericapillary halo diameter. Compression treatment achieves at least part of its effect by improving the function of the skin microcirculation. The efficacy of bandaging and stockings was similar.

Is there a vasospasmolytic effect of acupuncture in patients with secondary Raynaud phenomenon

Background: Raynaud phenomenon (RP) is a vasospastic disorder of the digital arteries. Severe forms are found in patients with connective tissue diseases. Vasospasmolytic therapies are often limited by side effects such as orthostatic hypotension.

Gefäßsport zur ambulanten Therapie venöser Durchblutungsstörungen der Beine Diagnostische, therapeutische und prognostische Aspekte

ZusammenfassungIn einer klinischen Untersuchung bei 33 Patienten mit chronischer Veneninsuffizienz aufgrund primärer Varikose oder eines postthrombotischen Syndroms in den klinischen Stadien I bis III nach Widmer konnte der Therapieerfolg eines halbjährigen krankheitsspezifischen ambulanten Bewegungstrainings dokumentiert werden. Während des Trainings kam es zu einer deutlichen Besserung stauungsbedingter subjektiver Beschwerden wie Schmerzen und Ödemneigung sowie zu einer Verbesserung von Sprunggelenkbeweglichkeit und venöser Abpumpleistung. Der klinische Erfolg zeigte sich in einer kompletten Abheilung venöser Ulzera bei 7 von 10 Patienten. In Verbindung mit einer optimierten Kompressionstherapie stellt die Gefäßsporttherapie eine effiziente und kostengünstige Basistherapie bei der CVI dar. Auf der Grundlage des novellierten Deutschen Behindertensportabkommens aus dem Jahre 1994 werden die Kosten von den gesetzlichen Krankenkassen getragen, solange das Training unter qualifizierter Anleitung indiziert ist.SummaryIn 33 patients with chronic venous incompetence (CVI) caused by primary varicoses or postthrombotic syndrome stage I–III (according to Widmer) the therapeutic benefit of 6 months of medically supervised physical exercise training was documented. During the training penud there was an improvement in subjective complains such as pain and tendency for edema in the legs. Mobility in the upper ankle joint was improved asuss as venous drainage function. Clinical benefit was achieved in the reduction of ulcer size; 7 of 10 ulcers completely healed. Medically supervised physical exercise training and optimized compression therapy are basic therapeutic approaches in conservative treatment in chronic venous insufficiency. Costs are covered by the patient’s health insurance company in Germany, as long as the exercise training is medically supervised.

The effect of compression therapy on venous haemodynamics in pregnant women

Objective To study the influence of compression on the haemodynamics o the deep venous system in pregnancy.

Wavelet analysis of cutaneous blood flow in melanocytic skin lesions.

Laser Doppler flowmetry (LDF) is frequently used to study the microcirculation. Usually LDF time series are analyzed by conventional linear methods, mainly Fourier analysis. The aim of this study was to observe dynamic blood perfusion of the skin in malignant and benign melanocytic skin lesions. Wavelet transformation was performed on each LDF time series in order to calculate a vasomotion field. First, the differences in vasomotion between healthy and pigmented skin were evaluated visually on six different time scales of the vasomotion field. In order to quantify the findings, vasomotion scale variance (VSV) was calculated for each scale plane of the vasomotion field. These VSV were compared using contrast ΔVSV to determine the difference between healthy skin and a pigmented skin lesion in the same patient. After the measurements, the skin lesions were excised and examined histologically. We found that wavelet analysis of LDF time series is a specific, sensitive method for the in vivo identification of malignant melanoma. It is a non-invasive procedure and takes minimal time to be carried out.

In Vivo Investigations of the Microcirculation in Venous Ulcers in View of Therapeutic Possibilities

Chronic venous incompetence is characterized by a stage-dependent microangiopathy. The more advanced the disease is, the more the vascular reserve and the number of cutaneous capillaries decrease (1,2,). These microangiopathic changes are probably among the causes of the trophic disturbances which accompany CVI. The aim of this study is to determine to what extent cutaneous microangiopathy changes or improves during healing.

Microcirculation in chronic venous insufficiency

Objective: To study the microcirculation of the skin of the leg in patients with chronic venous disease of the lower limb, and to assess the effect of compression treatment. Patients and Methods: Patients were recruited from the vascular clinic and investigated by direct capillary pressure, transcutaneous oxygen tension, intravital video capillaroscopy and fluorescence video microscopy. The microcirculation was observed over the healing period in patients with venous leg ulcers. The effects of compression therapy on microcirculatory changes were studied in patients with Widmer stage I and II chronic venous disease. Results: In patients suffering from lipodermatosclerosis or venous leg ulcers retrograde pressure waves were detected in the nutritive capillaries of the skin by the ‘servo nulling’ pressure measurement during simulated calf muscle contraction. A close correlation was found between the degree of trophic skin change and the microangiopathy observed. Healing of venous ulcers occurred only if the cutaneous microcirculation in the ulcer area improved. Capillary density in base of the ulcer and at the border predicted venous ulcer healing. Conclusions: Cutaneous microangiopathy precedes the development of trophic skin alterations due to chronic venous disease and microcirculatory changes are closely related to the clinical stage of the disease as well as to the outcome of treatment.